1. Diuretic Drugs Coagulation Modifier Drugs Antilipemic Drugs
Cardiac Drugs Part II
Diuretic Drugs
Coagulation Modifier Drugs
Antilipemic Drugs

2. The Kidney

3. Nephron
The microscopic filtration unit of the kidney, consisting the glomerulus, proximal convoluted tubule, loop of Henle, distal convoluted tubule, collecting duct, which empties urine into the ureters.

4. Glomerular Filtration Rate
GFR
Is a laboratory value the serves as a gauge of how well the kidneys are functioning as filters.
180 liters of blood filtered through kidneys per day.

5. Diuretic Drugs
All major classifications developed between 1950 and 1970 and are the most commonly prescribed drugs in the world.

6. Diuretic Drugs
Classified according to site of action

7. Classifications of Diuretics
Carbonic Anhydrase (Diamox): acts on the nephrons
Loop diuretics (Lasix): acts on the loop of Henle
Osmotic diuretics (Mannitol): works in the kidney on the glomerular filtration
Potassium sparing (Spiraldactone): works in the distal tubules
Thiazides (Diuril): works in distal tubules

8. 1. Carbonic Anhydrase Inhibitors
Action: inhibit the action of the enzyme carbonic anhydrase.
Site of action: nephrons
Indications: glaucoma, edema, epilepsy, and high altitude sickness.

9. Carbonic Anhyrase Inhibitors
Contraindications:
Drug allergy
Severe renal or hepatic dysfunction
Adrenal gland insufficiency

10. Adverse effects Drowsiness Anorexia Paresthesias
Hematuria (blood in urine)
Melena (blood in stool)

11. Interactions Increase in digoxin toxicity in clients taking digoxin.
Corticosteroids may cause hypokalemia.
Use with hypoglycemic drugs in diabetic type 2

12. Acetazolamine Trade name: Diamox
Classification: carbonic anhyrase inhibitor
Caution: check with patient regarding drug allergy to sulfonamides or significant liver or renal dysfunction.

13. Dosing Oral dosage for adults is 250 to 375 mg / day.
Oral dosing for pediatric patient is 5 mg / kg /day.

14. 2. Loop Diuretics Potent diuretics
The drugs act primarily along the thick ascending limb of the loop of Henle, blocking chloride and sodium resorption.
Also activate renal prostaglandins which results in dilation of blood vessels in kidneys and lungs and rest of body.

15. Loop Diuretics Used when rapid diuresis is needed.
Onset of action is1 hour and duration is 1-2 hours.
Usually given in a single daily dose

16. Major Side Effect Electrolyte imbalance
Especially sodium and potassium
Nurse alert: always check serum potassium and sodium levels before administering.

17. Good Effects of Loop Diuretics
Reduces blood pressure
Reduces pulmonary vascular resistance
Reduces systemic vascular resistance
Reduces central venous pressure
Reduces left ventricular end-diastolic pressure.

18. Contraindications
Drug allergy
Allergy to sulfonamides

19. Furosemide Trade name: Lasix Therapeutic classification: diuretic
Pharmacologic classification: loop diuretic
Primary use: pulmonary edema and edema associated with heart failure, liver disease and nephrotic syndrome.
Used in treatment of hypertension caused by heart failure.

20. Lasix Dosing
Adult: IV 0.5 to 1 mg / kg / dose (maximum 200 mg / day.

21. Drug calculation problem
Client weighs 170 pounds
Convert pounds to kilograms _________
Safe range of drug _______ to _______
Physician order: 56 mg of Lasix IV STAT

22. Drug calculation problem
Lasix is provided as 10 mg / mL
How much would you need to draw up to give the 56 mg?

23. 3. Osmotic Diuretics
Action: increases the osmotic pressure of the glomerular filtrate inhibiting the reabsorption of water and electrolytes.

24. When Used? Oliguric phase of acute renal failure.
Increased intracranial or intraocular pressure.

25. mannitol Trade name: Osmitrol, Resectisol
Therapeutic classification: diuretic
Pharmacologic classification: osmotic diuretic

26. mannitol adverse effects
CNS: confusion and headaches
EENT: blurred vision
Cardiovascular: transient fluid expansion, chest pain, CHF, pulmonary edema, tachycardia
GI: Nausea, vomiting and thirst
GU: urinary retention

27. Dosing Adult dosing: 500 mg / kg (Given in intravenous solution)
Onset 30 to 60 minutes
Peak 1 hour
Duration 6-8 hours

28. Nursing Assessment Monitor vital signs Urine output
Signs and symptoms of dehydration
Decreased skin turgor
Fever
Dry skin and mucous membranes
Low urine output

29. 4. Potassium Sparing Diuretics
Also called aldosterone-inhibiting diuretics because they block the aldosterone receptors.
This causes sodium and water to be excreted and potassium to be retained.

30. Potassium Sparing Diuretics
Action: drugs work in the collecting ducts and distal convoluted tubules, where they interfere with sodium-potassium exchange.

31. Indications
Used with other agents to treat edema or hypertension

32. Contraindications and Precautions
Use with caution in geriatric or debilitated patients or patients with diabetes mellitus (increased risk of hyperkalemia).
Renal insufficiency (BUN >30
History of gout or kidney stones

33. Adverse Reactions / Side Effects
CNS: dizziness, clumsiness, headache
Gastrointestinal: cramps, nausea, vomiting, diarrhea
Other: urinary frequency, weakness, hyperkalemia.

34. spironolactone Trade name: Aldactone
Therapeutic classification: diuretic
Pharmacological classification: potassium-sparing diuretic

35. Aldactone
Onset: unknown
Peak: 2-3 days
Duration: 2-3 days

36. Dosing PO Adults PO Children
mg per day as a single dose or 2-4 divided doses.
PO Children
1-3 mg / kg / day. Daily or 2-4 divided doses.

37. 5. Thiazides and Thiazide-Like Diuretics
Action: increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule.
Therapeutic effects: Lowering of blood pressure in hypertensive patients and diuresis with mobilization of edema.
Often the first drug used to lower blood pressure.

38. Contraindications Allergy to sulfonamides
Used cautiously in clients with renal or severe hepatic impairment.

39. Adverse Reactions and Side Effects
CNS: dizziness, drowsiness, lethargy and weakness
CV: hypotension
GI: anorexia, cramps, hepatitis,
Dermatology: photosensitivity, rashes
Fluid / electrolytes: Hypokalemia, dehydration, hyponatremia
MS: muscle cramps

40. hydrochlorothiazide Trade name: Esidrix, HydroDIURIL
Therapeutic classification: antihypertensive, diuretic
Indication:
management of mild to moderate hypertension
Treatment of edema associated with CHF, renal dysfunction, cirrhosis, corticosteroid therapy, hormonal therapy

41. Dosing
PO adults: 250 mg – 1 gram / day as a single dose or in divided doses
PO children > 6 months: mg/kg/day as a single dose or in divided doses.

42. HydroDIURIL
Onset 2 hours
Peak 3-6 hours
Duration 6-12 hours

43. Laboratory Considerations
Electrolytes especially potassium
Blood glucose
BUN
Serum Creatinine
Uric acid

44. Coagulation Modifier Drugs
Chapter 27

45. Anticoagulant
A substances that prevents or delays coagulations of the blood.

46. Antiplatelet Drugs
A substance that prevents platelet plugs from forming, which may be beneficial in defending the body against heart attacks and strokes.

47. Anticoagulants
Prevent the formation of a clot by inhibiting certain clotting factors called anticoagulants.
Only given prophylactically because they have no direct effect on a clot that has already formed.

48. Clots / Embolus
Clot: Insoluble solid elements of blood that have chemically separated from the liquid of plasma component of the blood.
Embolus: a blood clot that has been dislodged from the wall of a blood vessel and is traveling throughout the bloodstream.

49. Anticoagulants
Also called antithrombotic drugs because they all work to prevent the formation of clots or thrombus.

50. Embolus
Stoke or cerebral vascular accident occurs when a blood clot travels to the brain.
Pulmonary embolism occurs when a blood clot travels to the lungs.
Deep vein thrombosis or DVT: clot in the veins of the legs.

51. Anticoagulants
All anticoagulants work in the clotting cascade, but do so at different points.

52. Heparin Therapeutic classification: anticoagulants
Pharmacologic classification: Antithrobotic
Action of heparin is to turn off the coagulation pathway and prevent clots from forming.

53. Indications
Prophylaxis and treatment of various thromboembolic disorders including:
Venous thromboembolism
Pulmonary embolism
Atrial fibrillation with embolization
Acute and chronic coagulopahties
Used in low doses to maintain patency of IV catheters (heparin flush)

54. Contraindications Uncontrolled bleeding Severe thrombocytopenia
Open wounds
Use with caution:
Severe liver or kidney disease
Untreated hypertension
Ulcer disease
Spinal cord or brain injury

55. Heparin Use with extreme caution: Severe uncontrolled hypertension
Bacterial endocarditis
Bleeding disorders
Hemorrhagic stroke
GI bleeding / ulcers
Recent CNS or ophthalmologic surgery

56. Drugs that interact with heparin
Aspirin (salycilates)
NSAIDs

57. Dosing IV adults: IV children:
Intermittent bolus: 10,000 units followed by 5000 – 10,000 units q 4-6 hours
Continuous drip: 5000 units (35-70 units / kg)
SubQ: 800 to 10,000 units q 8 hours or 15,000 to 20,000 units every 12 hours
IV children:
Intermittent bolus: 50 units / kg followed by 100 units / kg q 4 hours.

58. warfarin Trade name: Coumadin
Therapeutic classification: antigoagulants
Pharmacologic classification: coumarins
Action: Interferes with hepatic synthesis of vitamin K – dependent clotting factors (II, VII, IX and X)
Used to prevent thromboembolic events

59. Adverse Reactions and Side Effects
GI: cramps and nausea
Derm: dermal necrosis
Hemat: Bleeding

60. Dosing
PO adults: 2.5 – 10 mg / day for 2-4 days and then dose adjusted by results of prothrombin time (PT) or international normalized ration (INR).
Use lower doses in the geriatric population.

61. Laboratory Values
Prothrombin time (PT): measures how long it takes a clot to form in a sample of blood.
PT 1.3 to 1.5
International normalization rate (INR): a standardized measure of coagulation achieved by drug therapy.
INR of 2.0 to 3.0

62. Nursing Responsibilities
Take exactly as directed
If a dose is missed take as soon possible
Do not double up on doses
Review food high in vitamin K
Vitamin K is antidote for warfarin overdose
Instruct on brushing teeth with soft brush.
Report any unusual bleeding or bruising

63. Foods high in Vitamin K Green leafy vegetables Prunes Noodles: spinach
Pie crusts

64. enoxaparin Trade name: Lovenox
Therapeutic classification: anticoagulant
Pharmacologic classification: antithrombotic
A prototype of heparin – replacing the use of heparin since laboratory values do not need to be monitored so tightly.

65. Lovenox
Action: Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin.
Used to control formation of emboli production post surgery.

66. Dosing DVT prophylaxis before knee / hip surgery
30 mg SC twice a day starting within 24 hours post-op and continuing for 7 – 10 days or until ambulating.

67. Deep Vein Thrombosis

68. Nursing Assessment Assess for signs of bleeding and hemorrhage
Bleeding gums
Nose bleed
Unusual bleeding
Black tarry stools
Hematuria
Fall in hematocrit
Bleeding from surgical site

69. Antiplatelet Drugs Generic name: salicylates
Trade name: Aspirin and aspirin combinations
Indication: prophylaxis of transient ischemic attacks and myocardial infarct.
Action: decreased platelet aggregation.

70. Antilipemic Drugs
Chapter 28

71. Cholesterol
A fat-soluble crystalline steroid alcohol found in animal fats and oils and egg yoke and widely distributed in the body especially in the bile, blood, brain tissue, liver kidneys, adrenal glands and myelin sheaths of nerve fibers.

72. Cholesterol Levels LDL: low density cholesterol
HDL: high density cholesterol (good cholesterol)

73. Why is high LDL a problem?
Atherosclerotic plaque formation
High correlation between Coronary Artery Disease (CAD) and high LDL and low HDL.

74. Treatment Guidelines Current guidelines recommendations:
LDL levels exceeding 190
LDL levels of 160 to 190 with CAD
Other risk factors
Waist circumference greater than 40 inches
Serum triglycerides of 150 or greater
HDL cholesterol less than 40
Blood pressure of 130/85 or higher
Fasting serum glucose greater than 110

75. Statins
A class of cholesterol-lowering drugs that are more formally known as HMG-CoA reductase inhibitors.
First classification developed in 1987.
Action: lower the blood cholesterol by decreasing the rate of cholesterol production.
Liver requires HMG-CoA reductase to produce cholesterol.

76. Contraindications Drug allergy Pregnancy
Liver disease or elevation of liver enzymes.

77. Adverse Effects Mild transient GI disturbances, rash and headache.
CNS: headache, dizziness, blurred vision, fatigue, nightmares, insomnia.
Severe side effect: muscle pain (myopathy)
Elevation of liver enzymes: need to be monitored about 6-8 weeks after therapy started and yearly thereafter.

78. atorvastatis
Lipitor
Most commonly used drug to lower LDL and raise HDL
Client needs to have liver enzymes drawn and cholesterol levels drawn 6-8 weeks after they start the drug therapy.
Call physician if muscle weakness is noted.

79. Niacin Niacin or nicotinc acid is another lipid lowering drug.
Higher doses are needed than available in OTC vitamins or niacin pills.
Adverse effects: flushing, pruritus (itching) and gastrointestinal disturbances.

80. Life Changes Diet: limit intake of high fat foods and animal proteins
Increase intake of omega oil contained in fish
Exercise
Weight control